Hospital to home transfers: resources and emerging good practice

Recent literature and resources to support good practice in timely hospital discharge.

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The LGA regularly updates its data tools on transfers of care. Similarly the Emergency Care Improvement Team produces a range of guides and tools. Additional resources are listed below in chronological order, most recent first, following feedback from users. If you have a resource you would like added to this list, please email chip@local.gov.uk. (Updated: 19 February 2018)


Housing, home and transfer of care
Formerly part of the Department of Health’ Care Service Improvement Partnership, the Housing Learning and Improvement Network reaches over 40,000 practitioners working across housing, health and adult social care. Its webpages contain a comprehensive set of relevant resources for commissioners that make the connection between housing, transfer of care and care pathways. They include a free selection of useful tools, guides and case studies on Delayed Transfers of Care.


Why not home, why not today? Putting a stop to DTOC; key findings – Newton Europe; November 2017

Why not home, why not today? Report

Why not home, why not today? Interactive presentation

This report will be of interest to colleagues working across health and social care, commissioners and providers. It explores the behaviours, findings and key causes identified in the analysis of three areas – Sheffield, North Cumbria and Fylde Coast. It also offers a practical approach and tangible suggestions for how others might use this experience to tackle delays in their own health and social care systems.


Developing trusted assessment schemes: essential elements – NHS Improvement; July 2017

This guide describes how local systems can implement trusted assessment, one of the eight High Impact Changes, to support timely hospital discharge and improve patient flow through urgent and emergency care.


High impact change model: managing transfers of care between hospital and home – Local Government Association; July 2017

A self-assessment tool for local care and health systems. It promotes a new approach to year round system resilience, moving away from a focus solely on winter pressures. It recognises that while there is no single solution to reducing delayed discharge from hospital, there is a system-wide commitment to work together to identify what can be done to improve current ways of working.


Winter Insight: the ambulance service – Nuffield Trust; April 2017

A briefing exploring the pressures faced by ambulance services in England.


Delayed transfers of care analysis – QualityWatch; updated March 2017

Regular analysis of data on delayed transfers of care produced by QualityWatch: the Nuffield Trust and the Health Foundation.


Making social care funding a priority for government – Care Quality Commission; March 2017

A think piece from Andrea Sutcliffe, Chief Inspector of Adult Social Care at the Care Quality Commission who said “to think that adult social care exists just to relieve pressure in the NHS by improving discharge from hospital for older people is [a] mistake.” It was published just after the 2017 Budget announcement.


Public satisfaction with the NHS and social care 2016 – The King’s Fund; March 2017

This report provides results and trends from the British Social Attitudes survey. Key findings cover public satisfaction with the NHS, social care services and A&E.


Delayed transfers of care resource search – Birmingham University; March 2017

A comprehensive review of the latest delayed transfers of care resources from leading stakeholders. Previous searches are available.


What's behind delayed transfers of care? – Nuffield Trust; February 2017

Blogs from Nigel Edwards on delayed transfers of care data.


Better transfers of care for older people – The King’s Fund; February 2017

Presentations from The King’s Fund conference on a range of topics:


Thought-provoking British Medical Journal blogs – David Oliver; 2016-17


Study into the pressures on acute hospital care – University of Birmingham School of Social Policy; September 2016

This report explores older people’s experiences of avoidable hospital admissions. It challenges the prevailing policy and media wisdom that large numbers of older people are admitted to hospital without really needing to go there because there is nowhere else for them to go.


Pressure Points: Carers and the NHS – Carers UK; September 2016

This report examines the role of carers in reducing emergency admissions and delayed transfers of care from hospital.


Social Care for Older People: Home Truths – The King’s Fund; September 2016

This report looks at the current state of social care services for older people. It considers the impact of cuts in council spending on social care providers and on older people, their families and carers.


Refer to Pharmacy: dedicated ward pharmacy model – NHS Providers; August 2016

A report on the impact on patient outcomes of a dedicated ward pharmacy model to reduce delays attributable to hospital pharmacies.


They're not bed blockers, just older people who want to get home – Johnny Marshall, NHS Confederation for the Guardian Policy Network; August 2016

An article about the importance of language when talking about delayed discharge and older people


Improving how community and hospital-based staff work together to ensure coordinated, person-centred support – National Institute for Clinical Excellence; August 2016

Implementing NICE’s guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs.


Discharging Older People from Acute Hospitals inquiry – UK Parliament; July 2016

A report following the Parliamentary Accounts Committee inquiry into discharging people from hospital and delays to transfer of care.


Delayed Transfers of Care Signposting resource – SCIE; March 2016

This resource was designed to help Better Care Fund Leads meet the 2016/17 BCF requirements on delayed transfers of care. Links were current at the time of publication – use this link for the current high impact change model).


Behind the Headlines: are older people and their families really to blame when their hospital discharges are delayed? – Age UK; March 2016

A report challenging that view that patients and their families are to blame for delays to hospital discharge.


Unit Costs of Health and Social Care – Personal Social Services Research Unit; 2016

A useful reference report compiling health and social care costs, for example, costs of a blue light trip to A&E.


Discharging older patients from hospital – National Audit Office; 2016

This report examines how effectively the health and social care system is managing the discharge of older patients from hospital.


Quick guides: transforming urgent and emergency care services in England – NHS England; 2015/16

A series of quick guides to support local health and care systems. They provide practical tips, case studies and links to useful documents, which can be used to implement solutions to commonly experienced issues. Topics include:


NICE Guideline (NG27):Transition between inpatient hospital settings and community or care home settings for adults with social care needs – National Institute for Clinical Excellence; December 2015

This guideline covers the transition between inpatient hospital settings and community or care homes for adults with social care needs. It aims to improve people's experience of admission to, and discharge from, hospital by better coordination of health and social care services.


Delayed Transfers of Care: a quick guide – The King’s Fund; November 2015

Definitions and answers to some key questions about delayed transfers of care: Why do delayed transfers of care occur? And what is the impact on the wider health system?


National Audit of Intermediate Care Summary Report 2015: assessing progress in services for older people aimed at maximising independence and reducing use of hospitals – NHS Benchmarking; November 2015

This report assessment of progress in community services aimed at maximising independence and reducing use of hospitals and care homes. It looks at four service categories: crisis response; home based intermediate care; bed based intermediate care; and reablement services). No audit undertaken in 2016. Access via subscription only.


Winter pressures: a Guide for Council Scrutiny – Centre for Public Scrutiny; November 2015

A practical guide providing advice on data sources and potential questions that council scrutiny might want to use when looking at local systems.


Right place, right time – better transfers of care: a call to action – NHS Providers; November 2015

A report into the causes and potential solutions to delayed transfers of care including messages for national organisations (page 8-10), messages for local government (page 11) and call to action checklist (pages 12-14).


Transforming urgent and emergency care services in England – NHS England; August 2015

A report for frontline providers and commissioners identifying good practice in delivering urgent and emergency care.


Safely home: What happens when people leave hospital and care settings? – Healthwatch England; July 2015

The findings of this report show that almost one in five people discharged from hospital in the previous three years did not feel that they had received all the social care support needed. Over one in five had not felt fully involved in decisions about their hospital treatment and plans for discharge. One in four carers felt the person could not cope in their own home after being discharged from hospital.


Commission on hospital care for frail older people – Health Service Journal; November 2014

This report addressed the problem of how the NHS should care for the country’s increasing numbers of frail older people. Please note that only the report headlines are available to view.


Avoiding unnecessary hospital admissions – Health Service Journal; May 2014

Mrs Andrews’ story: her failed care pathway, a YouTube video describing a patient’s personal experience of health and care.


What actions could be taken to reduce emergency admissions? – NHS England; March 2014

This presentation is designed to help commissioners by identifying strategies that can be adopted locally to reduce ambulatory care sensitive condition (ACSC) emergency admissions.


Delayed transfers: beyond the headlines – The King’s Fund; January 2014

Presentation by James Thompson exploring the then current data on delayed transfers of care. He focuses on the numbers and survey results from The King's Fund's quarterly monitoring report.


The ‘House of Care’ model – NHS England; October 2013

This model was created to challenge the way systems deal with long term conditions. The necessary building blocks of high quality, person-centred coordinated care are: commissioning; engaged, informed individuals and carers; organisational and clinical processes; and health and care professionals working in partnership.


Improving patient flow – Health Foundation; April 2013

This report looks at how two health trusts focused on flow to improve the quality of care and use available capacity effectively. It includes a useful list of other publications for further reading.


Seven Ways to No Delays – NHS Institute for Innovation and Improvement; January 2010

This guide outlines what clinical teams in both primary and secondary care should focus on to get the most out of time spent reviewing their services.